STATEMENT OF ASSETS, LIABILITIES AND NET WORTH AND DISCLOSURE OF BUSINESS INTERESTS, FINANCIAL CONNECTIONS AND RELATIVE/S IN THE

GOVERNMENT SERVICE As of December 31, ________ (Required by R.A. Nos. 3019 and 6713) (Note: Husband and Wife who are both public officials or employees may file the required statements jointly or separately.) Jointly filed. Separately filed.

Name _______________________________________________ Position _________________________________________ (Surname) (First Name) (Middle Initial) Office _________________________________________ Address ____________________________________________ Office Address __________________________________

I am married.

I am not married. Spouse ___________________________________________ Position _________________________________________ (Surname) (First Name) (Middle Initial) Office _________________________________________ Office Address __________________________________ Unmarried Children below 18 years of age living in his/her

household: (use additional sheet/s, if necessary) Name Date of Birth 1. _____________________________________________ ___________________________________ 2. _____________________________________________ ___________________________________ 3. _____________________________________________ ___________________________________ I have no children below 18 years of age living in my household. ASSETS, LIABILITIES AND NET WORTH I. ASSETS (including that of declarant s spouse and unmarried children below 18 years of age living in

his/her household) A. REAL PROPERTY/IES (use additional sheet/s, if necessary) KIND (Res./Comm./ Agri., etc.) NATURE OF PROPERTY (Paraphernal, conjugal or community) LOCATION ACQUISITION ASSESSED VALUE FAIR MARKET VALUE ACQUISITION COST* MODE YEAR Land, Building, others Improvement/s TOTAL: ________________ B. PERSONAL PROPERTY/IES AND OTHER ASSETS (use additional sheet/s, if necessary) TANGIBLE ACQUISITION ACQUISITION COST* MODE YEAR INTANGIBLE

TOTAL: _____________________ *For computation purposes, use acquisition cost. Properties of unmarried children below 18 years of age living in his/her household shall be excluded as well as the paraphernal/exclusive properties of spouse, in case of separate filing. TOTAL ASSETS (A+B)=___________________________ II. LIABILITIES (including that of declarant s spouse and unmarried children below 18

years of age living in his/her household) NATURE NAME OF CREDITOR/S *OUTSTANDING BALANCE (use additional sheet/s, if necessary) TOTAL: ___________________________ *In the computation of outstanding balance, properties of unmarried children below 18 years of age living in his/her household shall be excluded as well as the paraphernal/exclusive properties of spouse, in case of separate filing.

III. NET WORTH (TOTAL ASSETS (I) LESS TOTAL LIABILITIES (II) = NET WORTH (III) TOTAL NET WORTH: _____________________________ 1

AMOUNT AND SOURCES OF GROSS INCOME (ALL amounts received from ALL sources for the preceding calendar year) NATURE (salary/income, business, etc.) SOURCES AMOUNT (use additional sheet/s, if necessary) TOTAL: _______________________ AMOUNT OF PERSONAL AND FAMILY EXPENSES (for the preceding calendar year) PERSONAL EXPENSES ESTIMATED FAMILY EXPENSES ESTIMATED

AMOUNT AMOUNT (use additional sheet/s, if necessary) TOTAL : _______________ TOTAL : ______________ AMOUNT OF INCOME TAXES PAID (for the preceding calendar year) NATURE AMOUNT Compensation Business Income Other Income (use additional sheet/s, if necessary) TOTAL : _____________________________ BUSINESS INTERESTS AND FINANCIAL CONNECTIONS (Declarant/Spouse/Unmarried Children below

18 years of age living in the household of declarant) (Use Additional Sheet/s, if necessary) I/We don t have any business interests and financial connections. NameofEntity/BusinessEnterpriseBusinessAddressNatureofBusinessInterestand/orFina ncialConnectionDateofAcquisitionofInterestorConnection RELATIVE/S IN THE GOVERNMENT (Up to the 4th civil degree of relationship, either by consanguinity or affinity, including bilas, inso and balae) (Use Additional

Sheet/s, if necessary) I/We don t know of any relative/s in Government. NameofRelativeRelationshipPositionNameofOffice/Address I/We hereby certify that these are my/our true and detailed assets, liabilities, net worth, amount and sources of income, personal and family expenses, amount of income taxes paid, business interests, and financial connections, including those of my spouse and my/our children below 18 years

of age living in my household, and the name/s of my relative/s in the Government, as of December 31, __________, as required by and in accordance with Republic Act No. 3019 and 6713. I/We hereby authorize the Ombudsman or his duly authorized representative to obtain and secure from all appropriate agencies, including the Bureau of Internal Revenue, such

documents that may show such assets, liabilities, net worth, business interests, and financial connections, including those of my spouse and my/our children below 18 years of age living in my household, covering previous years, and if possible, including the year I/we first assumed office in Government. I/We further undertake to produce all supporting documents for each of the

entries herein made when required. Declarants Signature: __________________________ ______________________________ Date: ____________________________ Date: ____________________________ (For Separate Filing) Spouse s Signature: _________________________ Date: ____________________________ SUBSCRIBED AND SWORN TO before me on this _______ day of ______________, 20______, affiant(s) exhibiting his/her/their tax identification number(s) _______________________________ and employee number(s) ______________________________. (Person Administering Oath) 2